Recent research has acknowledged that impaired cognition is prevalent not only during depressive episodes but also following them, and may limit therapy outcome. In this blog post Jennifer Jordan and Richard Porter describe a study in which they examined the relationship between neuropsychological and depressive symptom change. One hundred and one patients were randomly assigned to schema therapy (ST) or cognitive behaviour therapy (CBT) for major depressive disorder. Results show that despite a significant improvement in depressive symptom severity, there were no significant improvements in neuropsychological functioning in both treatment modalities. The authors discuss this finding and suggest that inclusion of a specific cognitive training component in ST may enhance therapy effectiveness.

The presence of impaired cognition during depressive episodes is well recognised but the assumption was that these deficits were state dependent and would resolve with the remission of depressive symptoms. As a result, relatively little attention has been paid to these cognitive symptoms in the psychotherapy literature. More recently though, the focus has shifted to the persistence of cognitive dysfunction even when depression is improved and whether cognitive dysfunction might be a factor limiting our treatment outcomes and long term functioning in those with depression (1, 2).

Our current paper(3), examined the relationship of neuropsychological and depressive symptom change in a study of 101 adult outpatients participating in a randomised controlled trial of schema therapy (ST) versus cognitive behaviour therapy (CBT) for major depressive disorder (4). The duration of therapy was one year (6 months of weekly and 6 monthly maintenance sessions).

Neuropsychological testing took place at week 0 and week 16 in the depressed sample (n=69 completed the week 16 assessment) and matched healthy controls (n=58). Expected cognitive deficits were found in the depressed compared to the control group at baseline although only a few domains (verbal learning, memory and executive functioning) were related to depressive severity. Despite a reduction of 50% in depressive symptom severity by 16 weeks, there were no significant improvements in neuropsychological functioning in the depressed group once practice effects (benchmarked against the control group) were taken into account. There were no meaningful differences between CBT and ST, indicating that neither had any specific impact on cognitive dysfunction.

This finding of the lack of impact on cognition is not surprising at one level as cognition is not targeted in either CBT or ST. In fact there is surprisingly little evidence regarding the impact of psychotherapies or pharmacotherapy for depression on cognition, although the persistence of cognitive dysfunction despite improvement in depressive symptoms following treatment suggests that these most current treatments for depression are having little impact in this area (1).

Specifically addressing cognitive dysfunction might lead to improved longer term functional outcomes (2) however this has yet to be determined empirically.

Some more recent therapy developments such as metacognitive therapy (5) have specific strategies including cognitive training components targeting underlying cognitive dysfunction. There is preliminary evidence that cognitive training components embedded in psychotherapy might lead to improved cognition (see review 6). In another study by our team, metacognitive therapy (which has the attention training task) led to discernible changes in cognition by 12 weeks, over and above CBT, and independent of change in depressive symptoms (7).

The attention training task in metacognitive therapy prescribes practice of attentional skills and is designed to enable flexible control of attention, a core aspect of cognitive dysfunction. It also enhances meta-awareness of recurrent negative thinking processes (schema therapy’s “thinking traps”, arguably an essential common factor in all therapies.

In schema therapy, the key therapy goal is to enable the person to step back from acting reflexively in response to schema modes so that they can respond from a healthy adult perspective. By definition, schemas represent persistent rigid cognitive and emotional biases which are extremely difficult to disengage from.

Our findings above raise the question: Could adding a specific cognitive training component to schema therapy speed up and /or enhance the ability to disengage from these unhelpful rigid cognitive processes to enable more adaptive functioning?

Since the release of DSM-III-R in 1980, the categorical approach to diagnosing personality disorders (which has been retained in DSM-5 Section II) has been widely criticized for substantial shortcomings in terms of poor scientific validity and clinical utility. As a response to this, Young & Gluhoski (1996) proposed a dimensional schema-based model as an alternative approach to diagnosing, understanding, and treating personality disorders. Now, two decades after this proposal, an official dimensional system has been included in Section III of the DSM-5, and it largely aligns with the schema therapy model.

In this blog post, Bo Bach suggests that schema therapists may take advantage of the DSM-5 Section III personality dimensions in regard to case-formulation and targets of treatment. He explored the associations between the Young Schema Questionnaire 3 – Short Form (YSQ-S3), The Schema Mode Inventory (SMI), and The Personality Inventory for DSM-5 (PID-5) in a sample of 662 participants. Results indicate that the majority of DSM-5 trait dimensions were strongly associated with conceptually relevant schemas and modes. Thus, problems related to schemas and modes are now better communicated by means of an official diagnostic system than ever before.

Bo Bach

Clinical Psychologist and Research Associate

Psychiatric Research Unit – Region Zealand

Psychiatric Clinic Slagelse

Denmark

The Alternative DSM-5 Model for Personality Disorders

Section III of the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5) offers an alternative model for personality disorders intended to address the scientific problems of the categorical system (currently preserved in Section II), including within-diagnosis heterogeneity, excessive overlap with other diagnoses, and arbitrary categories that were developed from diverse traditions and clinical observations. For example, two different patients may both meet the categorical criteria for borderline personality disorder (5 of 9 criteria) but only have one symptom in common. Beyond describing overall personality functioning (Criterion A; severity), the alternative personality disorder model measures a range of scientifically based trait dimensions (Criterion B; style), which are the topic in this blog post. Similar to schemas and modes, all individuals can be located on spectra of trait dimensions. Accordingly, it is always valuable to know a person’s difficulties, implying that assessment of pathological trait dimensions may be relevant whether an individual has a personality disorder or not. Clinicians have free access to use the English version of the Personality Inventory for DSM-5 (see psychiatry.org), and to date the instrument is validated in Dutch, German, Italian, Danish, French, Spanish, and Norwegian translations. Soon a complete clinician-rated SCID-AMPD interview will be available to assess the complete Alternative Model for Personality Disorders.

What can the DSM-5 Section III dimensions do for schema therapists?

Since the trait dimensions are atheoretical in origin, they should be applicable across different frameworks of psychotherapy, including schema therapy, as would be expected from an official diagnostic system. Personality traits are commonly considered as descriptors of thoughts, feelings, and behavior, which in turn are viewed as manifestations of underlying processes. Therefore, we set out to investigate the alignment between the DSM-5 section III trait dimensions (25 traits) and schema therapy constructs (18 schemas and 14 modes). We proposed that uncovering such associations likely implies the clinical utility of the trait dimensions for developing case formulations with reference to related schemas and modes as treatment targets.

Associations between schema therapy constructs and the DSM-5 Section III dimensions were investigated in a mixed sample of 662 adults, including 312 psychiatric outpatients. All constructs were self-reported using the Danish validated versions of the Young Schema Questionnaire 3 – Short Form (YSQ-S3), The Schema Mode Inventory (SMI), and The Personality Inventory for DSM-5 (PID-5). Associations were examined in terms of factor loadings and regression coefficients in relation to five higher-order domains, followed by specific correlations among all constructs.

We demonstrated that the majority of trait dimensions are strongly associated with conceptually relevant schemas and modes. For example, the trait Submissiveness was substantially associated with the Subjugation schema, and likewise the trait Impulsivity was substantially associated with the Impulsive Child mode (see Table 1). Overall, we found that DSM-5 Personality Traits explained 89.4% of the variance of Schema Therapy constructs. This suggests that psychotherapists may be able to interpret and utilize DSM-5 traits as if they reflect schemas or modes. In addition, this may also add clinical understanding and utility to the DSM-5 trait model. Moreover, DSM-5 trait dimensions also add features such as eccentricity, perceptual dysregulation (dissociation), unusual beliefs and experiences, deceitfulness, and manipulativeness to individualized case-formulations, which are not covered by schema therapy constructs. Taken together, our findings supported the ability of specific facets to account for specific schemas and modes, which is explicitly useful for schema therapists who potentially could take advantage of this. In other words, schema therapists may be better placed for adopting a dimensional trait model in a future DSM-5.1 when the current personality disorder categories expectantly are omitted.

In this blog post, Veronique Dickhaut and Arnoud Arntz describe the development of a combined group and individual Schema Therapy (ST) protocol for the treatment of patients suffering from Borderline Personality Disorder, and the results of a pilot study based on that protocol. Patients who received combined group/individual ST showed greater improvement in comparison with those who received solely individual ST. Notably, these patients reached happiness levels almost equivalent those found in the general population. The blog concludes with an outline of the currently-running group ST international RCT.

Even before the ISST welcomed Joan Farrell and Ida Shaw at the 2008 Coimbra conference, ST therapists had been developing all kinds of group forms of schema therapy (ST). One such development took place in Maastricht, where the young trainee Veronique Dickhaut wanted to develop and test a form of group-ST for borderline personality disorder (BPD). Although I was initially reluctant, we agreed to try it out. To develop a protocol, we organized a small invitational conference where we discovered that the participants “agreed to disagree” on a range of issues. So we had to make decisions that might have been a bit arbitrary, including the decision that we would test a combination of individual and group ST. We reached this decision with the reasoning that each format meets a different kind of need (for individual attention and for being a member of a group of peers, etc.). We planned to study two cohorts of about 8-9 BPD patients each, in an uncontrolled design with 2 years of treatment, where we used a closed group format and where some patients were seen individually by the group therapists and others by other schema therapists (with collective peer supervision). Individual ST was allowed to be continued for an additional 6 months, gradually reducing the frequency of sessions.

About 6 months after starting the first cohrt, as our therapists were struggling with questions of how to handle the group dynamics and how to apply ST techniques in the group setting, we met Joan and Ida at the Coimbra conference, and learned that they had developed a very effective model based on more than 20 years of experience in delivering ST in groups. Following this meeting, our therapists received additional training from Joan and Ida - , before the 2nd cohort started, and around 1 year of treatment of the 1st cohort.

The results of our pilot study showed some interesting things. First, there was a clear indication that the 2nd cohort improved faster than the 1st cohort, whereas the 1st cohort – being a bit stuck at year 1 – started to catch up after the therapists changed to using the approach developed by Joan and Ida (see Figure 1). Second, the effects were large and seemed to be larger than in the individual ST study (Giesen-Bloo et al., 2006; see Figure 2). This indicates that the hypothesis that group-ST might catalyze change when delivered in the correct way, might be true (Farrell et al., 2009). Third, when we looked at the final mean level of happiness reached, participants reported a similar level as that of the general Dutch population (Figure 3). This indicates that the treatment not only reduced psychopathology, but also helped patients develop more fulfilling lives. Lastly, dropout was higher than that typical of individual ST – but note that dropout is generally higher in group than in individual treatments, e.g. because of scheduling problems.

The question of whether group-ST is effective for BPD when delivered as single or main treatment, or should be combined with individual ST, cannot be answered on theoretical grounds or on the basis of opinions of clinicians. And though the findings of our open trial described above are suggestive, they do not yet prove things… This is the main reason we embarked on the (currently-running) international RCT of group-ST for BPD (Wetzelaer et al., 2014), which examines this question empirically by comparing group ST in two formats (combined with individual therapy vs. intensive group therapy alone) to treatment-as-usual. We hope this ongoing study will help determine which modality is more effective and preferred by participants (both patients and therapists; see Wetzelaer et al., 2014).

Many patients with personality disorders also suffer from depression. However, little is known about the implications of such comorbidity for psychotherapy. In this blog post, Fritz Renner, Lotte L.M. Bamelis, Marcus J.H. Huibers, Anne Speckens, and Arnoud Arntz explore these implications with data taken from their larger research program comparing schema therapy to other psychotherapy techniques. Depressed patients with personality disorder recovered less during psychotherapy than did non-depressed patients. However, when controlling for the general severity of symptoms, there were no differences between the groups. These outcomes indicate that patients are less likely to recover from their personality disorder when their overall symptom severity is high.

Personality disorders and depression often go hand in hand: It is estimated that more than half of the patients with a personality disorder also suffer from depression. This high co-occurrence between personality disorders and depression can have important implications for the treatment of personality disorders and depression. For example, it is possible that treatment of a patient with depression would be complicated for patients who also have personality disorders. In fact, several studies have shown that depressed patients with co-morbid personality disorders indeed have worse treatment outcomes; however, it is notable that other studies do not support this finding. Another important question that has not been investigated in randomized controlled trials so far is whether the presence of depressive disorders complicates the treatment of personality disorders and therefore has a negative impact on treatment outcomes in patients with personality disorders.

We addressed this question empirically by drawing data from a recent large randomized controlled trial on the (cost-)effectiveness of schema therapy for personality disorders (Bamelis, Evers, Spinhoven, & Arntz, 2014). Participants in this study fulfilled the criteria for either cluster-C (92% of participants) and/or for histrionic, narcissistic or paranoid personality disorder. Participants were randomly allocated to receive either 50 sessions of schema therapy (n = 147), treatment-as-usual (duration clinically decided) (n = 135), or (open-ended) clarification-oriented psychotherapy (n = 41). The main results of this study are reported in Bamelis et al. (2014).

Forty-four percent of the patients in this study also met diagnostic criteria for depression. We expected that those with co-occurring depression would recover less often from their personality disorder and show more impairment in psychosocial functioning at the end of the three-year study phase when compared to those with no co-occurring depression. We were also interested in exploring whether these findings would differ between the three treatments.

In line with our hypothesis, personality disorder patients who also met diagnostic criteria for depression recovered less often at the end of the three-year study period when compared with personality disorder patients who did not meet diagnostic criteria for depression. However, when we controlled for the general severity of symptoms the two groups did not differ anymore in their recovery rates. This means that it is not the depression per se that complicates treatment of personality disorders and therefore leads to lower recovery rates but rather the overall severity of symptoms with which personality disorder patients present upon entering treatment. These findings were the same for all three treatments in the study. Another finding was that personality disorder patients with depression had poorer levels of psychosocial functioning before and after treatment compared to those without co-occurring depression and this effect reduced, but remained, when controlling for general symptom severity.

What do these findings mean for clinicians using schema therapy?

These findings suggest that the presence of depression in personality disorder patients is not an obstacle to improve in treatment. However, patients who present with an overall higher general symptom severity upon entering treatment are less likely to recover from their personality disorder. Note that this is true for all treatments under investigation in this study and not only schema therapy. Importantly, patients with personality disorders who are also depressed are likely to experience more psychosocial problems before and after treatment and it is possible that these patients could benefit from treating depression in schema therapy (or other treatments) in addition to treating the underlying personality disorder.

Little is known regarding the effectiveness of clinical training or regarding training components which contribute to it. In this blog post, Deborah Kingston, Nima Moghaddam, and Kerry Beckley describe a study aimed to evaluate a Schema Therapy (ST) training programme. The programme consisted of a 3-day multicomponent approach workshop which included didactic, experiential, and reflective foci. The authors evaluated the nineteen trainees’ knowledge, confidence, and willingness to use ST at three time points: pre-training, post-training, and at a 3-month follow-up. Significant changes were observed from pre- to post-training in the knowledge and the confidence measures but not in the willingness one. Retention of learning was indicated, with no differences between post-training and follow-up assessments. Additional qualitative measures were collected and are discussed.

Trainee clinical psychologists are taught to select and apply the ‘right’ evidence-based treatment approach for each client’s presenting problems. However, clinical psychology training courses in the UK focus on developing competence in just two evidence-based approaches (Cognitive Behavioural Therapy plus one other) – leaving trainees with limited scope for selection/application according to individual client need. In our local region, trainees identified specific deficits in their ability to work with more complex presentations – particularly clients who present with personality difficulties or ’disorder’ – and consequently requested an opportunity to attend extra-curricular training in Schema Therapy (as an evidence-based approach for working with more complex presentations). Our study reports on the effectiveness of a Schema Therapy training programme that was designed to address trainee learning requirements.

There is a dearth of literature examining the effectiveness of training – or even whether training-related gains in knowledge and confidence are maintained and translated in to clinical practice – and ours was the first published study to evaluate a Schema Therapy (ST) training programme.

The model of training which informed the implemented training programme was one of experiential learning and reflection. In terms of underpinning theory, Kolb’s (1984) model was central to the training approach. The training delivery was further augmented through the process of didactic teaching and expert modeling. This multicomponent approach (including didactic, experiential, and reflective foci) was intended to encourage transfer of knowledge and techniques from the learning environment into clinical practice. The value of multicomponent training approaches has been supported empirically (Herschell, Kolko, Baumann & Davis, 2010) with evidence to suggest that different components have differential effectiveness (Bennett-Levy, McManus, Westling & Fennell, 2009). The training programme also mirrored the delivery of ST in clinical practice, in that participants were able to experience both client and therapist roles. Such techniques are core to the ST approach, their aim being to both activate the emotional content of schemas and also to provide corrective emotional experiences using experiential techniques such as imagery, re-scripting or chair work in the context of meeting unmet childhood needs. Table 1 provides an overview of the evaluated training programme.

This study aimed to evaluate the ST training programme by:

1) Reviewing whether ST training increases knowledge, confidence and willingness to use ST and whether any gains were sustained at follow-up.

2) Examining whether an increase in knowledge, confidence and willingness were associated with subsequent use of ST in clinical practice.

3) Identifying facilitators/barriers to using ST in clinical practice.

The training was provided by a qualified Schema Therapist (the third author) who developed the training programme as a 3-day workshop, tailored to trainee learning needs (contents can be found in the journal article). Bespoke questionnaires were developed to capture knowledge, confidence, and willingness at three time-points: (1) start of training, (2) end of training, and (3) 3 months post-training (follow-up). The follow-up questionnaire included additional free-text boxes to capture barriers/facilitators to using ST in practice.

Nineteen participants enrolled on the training programme; most (18; 95%) were in their first or second year of their three-year doctoral training in clinical psychology. A series of one-way repeated ANOVAs were conducted comparing aggregated scores (in knowledge, confidence, and willingness to practice ST) across three time points. We further examined disaggregated (individual-level) changes by applying Reliable Change Index (RCI) computations (Jacobson & Truax, 1991).

Analysis of group-level changes indicated that participants’ knowledge and confidence around the use of Schema Therapy increased from pre- to post-training, and that gains were sustained at 3-month follow-up. Explanatory content analysis of qualitative responses indicated that maintenance of gains was afforded by the opportunity to implement Schema Therapy in clinical practice. Reported willingness to use Schema Therapy also showed an increase from pre-training to follow-up. When exploring individual-level change (RCI), 9/17 (53%) of group participants reported statistically reliable improvements in knowledge from pre- to post- training. No individuals showed reliable change between post-training and follow-up – suggesting retention of learning. The proportion of individuals showing reliable change was higher in the confidence domain: wherein 11/17 (65%) of group participants reported reliable pre- to post-training increments in their confidence with Schema Therapy concepts and techniques. When exploring willingness to use ST, only 2/17 (12%) of group participants reported reliable change from pre- to post-training. Limited change in this domain may be attributed to ceiling affects, as pre-training willingness was relatively high, which might have been expected in a sample of individuals seeking training. Qualitative analysis indicated that there were a number of facilitators and barriers to using ST in practice; factors moderating transfer into practice were: (1) type of placement, (2) supervision, (3) personal factors, and (4) training processes.

There are a number of limitations to this evaluation. Principally, findings were subject to self-report biases. For example, participants may have been motivated to under-report pre-training knowledge and confidence and subsequently over-report training related gains. Similarly, reports of application in practice were not independently verified. Future evaluations would benefit from objective measures, such as behavioural observations or testing of knowledge and skills through case studies, role plays or written assessments.

This study contributes to the wider evidence-base supporting the effectiveness of workshop-style training and its potential transferability into clinical practice. From our analysis of factors that moderated transfer into practice, we believe that future training could be refined through attention to the theoretical principles outlined by Bennett-Levy (2006), who posited that therapists in training need to (1) reflect on declarative knowledge (knowing the theory; e.g., principles and concepts), (2) reflect on procedural knowledge (knowing what they do; e.g., two chair work, imagery), and (3) reflect on both declarative and procedural aspects (knowing what to do and when to do it).

Whereas group schema therapy for Borderline Personality Disorder has shown promising results, little is known about its effects for other personality disorders. In this blog post, Susan Simpson, Sally Skewes, Rachel Samson, and Michiel van Vreeswijk describe a pilot study using short-term group schema therapy in a case series of eight patients with different personality disorders. Overall, a majority of the patients showed significant improvement both at treatment’s end, and in the follow-up.

Dr Susan SimpsonDivision of Education, Arts and Social Sciences
Clinic Director,School of Psychology, Social Work and Social PolicyUniversity of South Australia

Sally SkewesSchool of Psychology, Social Work and Social PolicyUniversity of South Australia

Rachel Samson

School of Psychology, Social Work and Social Policy

University of South Australia

Michiel van Vreeswijk

G-kracht Psychomedisch Centrum BV, Delft, Netherlands

Preliminary evidence supports the use of group schema therapy for Borderline Personality Disorder (BPD); however, evidence supporting the use of group schema therapy with other personality disorders or indeed those with mixed personality disorders is sparse. However, in most clinical settings, it is often more common at any given point in time to encounter patients with a range of personality disorders than to have a caseload or waiting list consisting of any one specific personality disorder.

We conducted a pilot study using short-term group schema therapy (ST-g) in a case series of eight patients with Cluster A, B, and C personality disorders and high levels of comorbidity. Treatment comprised 20 sessions that included cognitive, behavioral, interpersonal, and experiential techniques.

Six participants attended until end of treatment and two dropped-out before mid-treatment. All outcome measures showed changes in treatment completers with large effect sizes in depression, anxiety, and avoidant personality disorder symptom severity levels between pre-therapy and follow-up. Four participants no longer met criteria for personality disorder diagnosis at the end of therapy. By follow-up, five participants had achieved a loss of diagnosis, suggesting that participants derived ongoing benefits from the group even after treatment ended. All six completers no longer met criteria for depression at the end of treatment; this was maintained for all participants at 6-month follow-up. At follow-up, the majority of participants showed clinically significant change on the Global Symptom Index (GSI). The majority of participants showed a reduction in maladaptive modes on the Schema Mode Inventory (SMI) at follow-up. Additionally, 40% of participants showed clinically significant change on the SMI adaptive modes at follow-up. Qualitative feedback indicated that the group helped to normalize participants' emotional experiences and difficulties and promoted self-expression and self-disclosure, while reducing inhibition.

Although there are limitations to our pilot study such as the small sample size and lack of control group, this naturalistic pilot study allowed a rich and detailed exploration of the level of change possible over a 20 week schema therapy group with a mixed personality disorder sample. Naturalistic designs are clinically useful and have high ecological validity, which can allow results to be generalized to patients generally seen in typical clinical settings (i.e., community mental health teams, hospital wards).

What could this research mean?

This study may have implications for the significant number of patients with personality disorders who may not respond to conventional treatments offered within many health service settings. In particular, those with Cluster C personality disorders can remain ‘stuck’ in long-term individual therapy frequently avoiding behavioural and interpersonal changes. Their avoidant and rigid coping mechanisms can be difficult to challenge in individual work, even with relentless empathic confrontation and behavioural task setting. However, group therapy can provide a natural (but safe) environment whereby participants can learn to challenge and actively encourage each other to make changes. Indeed, schemas are regularly triggered within the group setting through interpersonal group dynamics, thereby providing an ideal setting for addressing schema perpetuation processes as they are occurring.

In particular, the mixed nature of the personality disorder group included in our study facilitates active participation amongst group members. We find that there are usually enough schemas and modes in common amongst group members to enable participants to feel understood and bonded to the group, whilst the differences enable them to react differently and to challenge each other more intensely. Unsurprisingly, those with BPD tend to be able to be more emotionally expressive, and can empower those with Cluster C personality disorders to begin to gradually explore the possibility of reducing avoidance and connecting with their own vulnerability. The discussions generated around underlying schemas and modes can also enable participants to learn as a group how to generate feelings of safety around their vulnerability, as well as how to be compassionate toward their own and others’ Vulnerable Child modes.

This study contributes to a growing body of literature that suggests that ST-g shows promise as an intervention which may stimulate avoidant coping patterns through experiential, cognitive and behavioral group processes, many of which appear to be unique to working in a group setting.

Theoretically, Early Maladaptive Schemas (EMSs) develop due to marked frustrations of the child’s core needs.In this blog post, Asle Hoffart and Synve Hoffart Lunding describe an empirical examination of this statement. In their study, they explored the relationships between parental bonding, EMSs, and outcome in schema therapy of personality problems. Forty-five patients with panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits participated in an 11-week inpatient schema-based program. Notable results included relations between: maternal protection and schema domains of impaired autonomy and exaggerated standards; lower paternal care and more reduction in Cluster C personality traits from pre-treatment to one-year follow-up. Additionally, perceived maternal care was reduced from pre-treatment to one-year follow-up, and more reduction in maternal care was related to less reduction in Cluster C traits.

Synve Hoffart Lunding

Child and Adolescent Mental Health Services in Stockholm County, Sweden

Asle Hoffart

Research Institute, Modum Bad, Vikersund, Norway

Schema therapy (Young et al., 2003) is a modification of standard cognitive therapy purported to adapt to the specific needs of patients with personality disorders and/or more chronic anxiety and depressive disorders. Central in the schema therapy model is the concept of Early Maladaptive Schemas (EMSs), which represent oneself and one’s relationship with others. EMSs typically develop in the wake of adverse experiences involving marked frustrations of the child’s core needs for connectedness, autonomy, worthiness, reasonable expectations, and realistic limits. For instance, a child may be overly criticized when he/she does not meet parental standards and develop a defectiveness/shame EMS. Based on clinical experience, Young (1990) formulated a list of EMSs which are assumed to cluster in five schema domains each reflecting frustrations of one of the core needs referred to above.

We conducted a study to examine the relationship between parental bonding, schema domains/EMSs, and outcome in schema therapy of personality problems. Patients with panic disorder and/or agoraphobia and DSM-IV Cluster C personality traits (n = 45) who participated in an 11-week inpatient program were studied. The program consisted of two phases: the first phase was five-week panic/agoraphobia-focused, while the second six-week phase was personality-focused and based on Young’s (1990) schema-focused approach. We expected that non-optimal parenting (low care, high protection) would influence EMSs/schema domains and that the EMSs/schema domains in turn would influence how the patients engaged in therapy - and thus, respond to it.

Opposite to our hypothesis, lower paternal care at pre-treatment was related to more reduction in Cluster C personality traits from pre-treatment to one-year follow-up. Maternal protection was related to the schema domains of impaired autonomy and exaggerated standards (see Table). Overall schema severity and the specific severity of the emotional inhibition schema at pre-treatment were associated with less change in Cluster C traits. Perceived maternal care was reduced from pre-treatment to one-year follow-up, and more reduction in maternal care was related to less reduction in Cluster C traits.

Our conclusions were:

·Most schemas within the impaired autonomy domain and the self-sacrifice schema seem to be related to high perceived maternal protection.

· Overall schema severity and the emotional inhibition schema predict poorer outcome of schema therapy of Cluster C personality problems, and therapy should give priority to emotional inhibition when this schema is endorsed.

· Therapists should be aware that schema therapy carries the risk to lead to a more negative view of mother’s care during upbringing and this risk is accentuated with less benefit of therapy.

Table. Correlations between dimensions of parental bonding and schema domains

Schema domain

PBI subscale

Disconnection

Impaired

Autonomy

Exaggerated

Standards

Impaired

Limits

Maternal care

-.21

-.02

-.24

.00

Paternal care

-.07

.09

-.03

.04

Maternal protection

.13

.39*

.51**

.26

Paternal protection

.08

.01

.17

-.02

*p < .05; **p < .001. PBI = Parental Bonding Instrument. Note that we used an empirically derived ordering of schema domains into 4 instead of the five domain structure proposed by Young (1990).

The limited success of most therapies available for treating chronic depression means there is a strong need for development of new treatments for this debilitating condition. In this blog post, Ioannis Malogiannis describes results of a pilot study of 12 chronically depressed patients treated with an adapted form of schema therapy, lasting 60 sessions. At the end of treatment, approximately 60% of the patients remitted or responded to therapy. This exciting pilot study supports the use of schema therapy as an effective treatment for chronic depression.

The nosological entity of chronic depression is a new challenge for Schema Therapy (ST). Chronic depression is a difficult to treat mental disorder, associated with increased functional impairment, suicide attempts and health care utilization. Early adversity, comorbid personality disorders and Early Maladaptive Schemas are the main determinants of chronic depression. Although several pharmacological and psychotherapeutic interventions have been developed for the treatment of chronic depression, the effect sizes are small, a substantial proportion of patients remain depressed and most trials suffer from lack of maintenance of their results.

The existing literature stresses the need for development of new treatments, more intensive, lengthier, dealing with personality pathology for chronically depressed patients. The limited effectiveness of the existing interventions and the effective focus of ST work on the all the determinants of chronic depression support the idea to investigate the implementation of ST in chronic depression.

We conducted a pilot single case series study. The protocol consisted of 60 sessions as follows: 12-16 initial sessions of introduction to ST and bonding between patient and therapist and then the main phase of ST provision up to 60 sessions. 12 chronically depressed patients participated. Patients were assessed three times during an 8-week baseline period, then at the end of the introductory phase, and again every 12 sessions up to the end of treatment and finally at a 6-month follow up.

At the end of treatment 7 patients (approximately 60%) remitted or responded to therapy. Depressive and anxiety symptoms significantly decreased during treatment, the effect sizes were large and maintained in the 6-months follow-up. A significant decrease of depression and anxiety symptoms was reported after the introductory phase. This effect was attributed to the use of an extremely nurturing therapeutic stance from the beginning of the intervention – one using the frame of limited re-parenting. After this phase, deterioration regarding depressive symptoms was found at the second or later assessments. This was explained as a result of the use of experiential techniques and the focus of therapeutic work on early traumatic experiences.As therapy progressed, experiential work and reparenting fulfilled the unmet core emotional needs and changed schemas and modes resulting in more lasting changes. (The Figure below presents the change of depressive symptoms, measured by the Hamilton Rating Scale for Depression - HRSD, during treatment and the 6-month follow-up)

This pilot study supports the use of ST as an effective treatment forchronic depression. A Randomized Controlled Trial(RCT)of Group Schema Therapy for chronically depressed patients isnowbeing prepared and will be implemented by our group in the next months.

The view of the treatability of personality disorders has changed dramatically over the past thirty years. Unfortunately, the pessimism with regard to personality disorders has persisted with regard to one group: forensic patients with personality disorders, especially patients with Antisocial Personality Disorder and Psychopathy. Interestingly, new scientific evidence is beginning to challenge the pessimistic view regarding such patients. In this blog post, David Bernstein tells us about the development and empirical status of his exciting work developing and disseminating schema therapy for forensic patients.

When I was a young psychologist in training, the prospect for treating patients with personality disorders was decidedly pessimistic. I was told that people with personality disorders had little motivation to change or engage in therapy, because they weren’t suffering enough. According to one of my professors, “They don’t suffer themselves, but they do make other people suffer!” This view was so prevalent that many mental health professionals didn’t want to work with patients with personality disorders. During my clinical internship year, I observed that some staff members at the psychiatric hospital where I worked literally walked the other way when they saw a patient with Borderline Personality Disorder walking towards them. Yet, how does the view that patients with personality disorders don’t suffer accord with the fact that ten percent of individuals with Borderline Personality Disorder will commit suicide during their lifetime?

Fortunately, the view of the treatability of personality disorders has changed dramatically over the past thirty years. Marsha Linehan was the first to show that a specialized therapy, Dialectical Behavior Therapy, could greatly reduce the risk of suicide and self-harm behaviors in patients with Borderline Personality Disorder. Jeffrey Young introduced Schema Therapy, which went a step further. Studies show that Schema Therapy, which focuses on patients’ unmet emotional needs, reduces suicide risk while also improving core symptoms such as identity confusion and unstable relationships, and enhancing the quality of life in these individuals. These and other specialized treatments have brought new hope to people with personality disorders, who were often considered untreatable, while changing attitudes for the better in those who work with them.

Unfortunately, the pessimism with regard to personality disorders has persisted with regard to one group: forensic patients with personality disorders, especially patients with Antisocial Personality Disorder and Psychopathy. In forensic settings around the world, like forensic hospitals and prisons, personality disorders are the most prevalent form of psychiatric disorder. Antisocial Personality Disorder, which is defined in the DSM-V largely by a persistent pattern of antisocial behavior, affects up to eighty percent of the people in these institutions. Within this broadly antisocial group, the most severe subgroup is the so-called psychopaths, who have core psychopathic personality traits such as ruthlessness, callousness, and remorselessness. Research shows that twenty to thirty percent of individuals with Antisocial Personality Disorder also have significant traits of psychopathy. Compared with other individuals in forensic populations, psychopaths have much higher rates of recidivism and are more likely to commit severe offenses and acts of violence. Psychopathic individuals are often described as unmotivated for treatment. In fact, there is a widespread belief that therapy will only make them worse, teaching them the psychological skills to better con and manipulate other people. Research also shows that psychopaths have deficits in emotional functioning. And, of course, the frequent depiction in the media of psychopaths as inhuman monsters makes a powerful impression. Taken together, is it any wonder that many people believe that forensic patients with personality disorders, and especially psychopathic ones, are untreatable?

Interestingly, new scientific evidence is beginning to challenge these widespread views. First, research shows that environmental factors, such as childhood trauma, parental neglect, inadequate attachments to caregivers, antisocial peer groups, and growing up in impoverished and violent communities, play an important role in the development of Antisocial Personality Disorder and Psychopathy. These environmental influences are likely to interact with genetic vulnerabilities, such as inherited predispositions to emotional callousness and impulsivity, increasing the risk for antisocial behavior and psychopathic traits. Psychopaths appear to be a much more diverse group than we ever realized, both in terms of the causes of the disorder, and the kinds of emotional problems that they exhibit. While some psychopaths are emotionally under-responsive, others may be prone to strong emotions, such as anxiety, depression, and anger. Perhaps some of these diverse patients are more responsive to treatment than others.

Second, there is actually very little evidence that psychopathic patients cannot be treated, or that therapy will make them worse. In fact, most of the treatment studies of psychopaths have been marred by serious methodological problems. For example, the most famous study to show that treatment made psychopaths worse, carried out at a Canadian prison in the 1960’s, would never pass muster with an ethical review board today. The patients in the study were given a number of bizarre treatments, including psychedelic drugs such as LSD and participating in naked encounter groups, in an effort to break down their defenses. The “treatment” was largely given by the patients themselves, who could even prescribe their own medications, with little involvement of professionals. What are we to make of the finding that the psychopathic patients in this study had a higher rate of recidivism when followed up years later, compared to other patients? Yet, this study has until recently often been cited by experts as evidence that treatment makes psychopaths worse. Could it be possible that the field has been engaging in a self-fulfilling prophesy, withholding treatments from psychopathic patients on the basis of a largely unsupported belief? Psychopaths undoubtedly pose challenges, which should not be underestimated. However, it may be possible that, as was the case for Borderline Personality Disorder, our own views have blinded us to the potential for treating them.

My own research investigates the final frontier regarding the treatability of personality disorder patients. Can psychotherapy help forensic patients with personality disorders, including psychopathic ones, recover and lead safer and more productive lives? Since 2007, my colleagues and I have been conducting a large randomized clinical trial of the effectiveness of Schema Therapy at seven forensic hospitals (“TBS clinics”) in the Netherlands. One hundred and three patients are enrolled in our randomized clinical trial; fifty four were randomly assigned to receive three years of Schema Therapy, while the other forty nine received a comparable duration of usual forensic treatment at these institutions (“treatment as usual”). The patients were all male and had a DSM-IV diagnosis of Antisocial, Borderline, Narcissistic, or Paranoid Personality Disorder, or significant traits of these disorders (“Cluster B Personality Disorder Not Otherwise Specified”). We are particularly interested in seeing if Schema Therapy reduces recidivism risk and maladaptive personality traits, and speeds patients’ re-entry into the community, compared to treatment-as-usual. After treatment is completed, we will follow these patients for an additional three years, after many of them have returned to the community, to determine which ones have recidivated. The treatment phase of the study will be completed by August of 2015, while the three year follow-up will be completed by 2018.

Our preliminary findings suggest that Schema Therapy is outperforming treatment-as-usual. The patients who received Schema Therapy are showing more rapid reductions in their risk of recidivism, and are moving more quickly through the process of resocialization, where patients gradually re-enter the community under decreasing levels of supervision. These trends were already apparent when we analyzed the data in the first thirty patients to complete the study, but were not yet statistically significant in this small initial sample. However, these trends have persisted as we have continued to analyze our findings. We are waiting with bated breath for the final results of the study, which we will analyze later this year and submit for publication by the end of 2015. The Netherlands’ Erkenningscommissie (“Recognition Commission”) was sufficiently impressed by our findings that they have provisionally certified Schema Therapy as the first officially recognized evidence-based treatment for personality disorders in forensic patients. To my knowledge, this makes Schema Therapy the only evidence-based treatment for forensic patients with personality disorders that is recognized in any country.

Will Schema Therapy be significantly more effective for forensic patients with personality disorders, including psychopathic patients who are usually considered to be untreatable? Stay tuned! In the meantime, we have recently published a case study of our first, apparently successful treatment of a psychopathic patient with Schema Therapy. The article describes the therapy process for this psychopathic patient and uses multiple forms of assessment to measure his progress over a period of seven years. Three years after completing treatment, he was still crime-free, living in the community, holding down a job, and living in a stable relationship with his new partner and their child. Schema Therapy offers no guarantees for forensic patients with personality disorders. However, we do aim to reduce the risk of crime and violence in these patients, a goal that is of great importance for society. And perhaps our research can begin to change some attitudes about supposedly untreatable forensic patients with personality disorders.

We have come a long way since the anecdotal finding in the clinical literature that inpatient treatment may be harmful for patients with BPD. In this brief summary, Neele Reiss (lead author of the recent report on three pilot studies testing inpatient schema therapy) tells us about the development, and empirical status, of this exciting mode of delivering schema therapy to patients with BPD.

Schema Therapy can be delivered in an individual or group format and both formats have demonstrated effectiveness in treating Borderline Personality Disorder (BPD) in the outpatient setting. However, the most severely impaired BPD patients are often referred to inpatient treatment due to suicidality and severe self-harm. Few specialized inpatient Schema Therapy treatment programs, combining elements of individual and group Schema Therapy, exist, and these need to be evaluated to determine their effectiveness.

As a first step in examining the effectiveness of new treatment programs in these naturalistic clinical settings, three independent uncontrolled pilot studies of intensive inpatient ST treatment programs (each with 9.5 hours of Schema Therapy per week) with a total of 92 BPD patients were conducted. We found that inpatient ST can significantly reduce symptoms of severe BPD and global severity of psychopathology.

Interestingly, the amount of symptom reduction achieved differed significantly between the three pilot studies. This could be explained by variations in length of treatment (ranging from an average of 10 weeks to 18 weeks), number of group psychotherapists (1 vs 2 group therapists) and their training (experts vs beginners). Although there are limitations to our pilot studies such as differences in the samples, treatment settings, variations in the treatment itself and the use of different measures, which may have influenced outcome, they are a starting point for describing and evaluating inpatient treatment for BPD in naturalistic settings.

What could this mean? If you are treating severely impaired BPD patients, who suffer from symptoms that make outpatient treatment dangerous to you as a therapist or your patient, referring your patient to an intensive inpatient Schema Therapy treatment program is an option to consider. However, it looks like several factors influence how effective the inpatient ST program would be for your patient, so watch out for the dosage of therapy your patient is getting (how many hours per week for how long?) and how the group schema therapy component is administered (how many therapists in the group, training of therapists).

Why Schema Therapy?

Schema therapy has been extensively researched to effectively treat a wide variety of typically treatment resistant conditions, including Borderline Personality Disorder and Narcissistic Personality Disorder. Read our summary of the latest research comparing the dramatic results of schema therapy compared to other standard models of psychotherapy.

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